ABSTRACTObjective:Â  Prescription writing is an art. Writing a correct prescription in compliance with the WHO guidelines requires regular practice. Mistakesin prescription writing are inevitable. Hence, this study was done to analyze the prescriptions from the Outpatient Department of Obstetrics andGynaecology for errors. To analyze the prevalence and types of common prescribing errors in the Outpatient Department of Obstetrics and Gynaecology.Methods:Â  This cross-sectional study was conducted in the Department of Pharmacy, Pondicherry Institute of Medical Sciences, Puducherry. 500prescriptions from the Obstetrics and Gynaecology Outpatient Department were collected and analyzed. The study duration was 6 months (JulyDecember2014). The prescriptionswereanalyzedforerrors.Results: Our study revealed that 30.8% of the prescriptions had, at least, one error in them. The majority of the prescriptions had the doctors' signand patient details written in them. The dose of the drug was missing in about 38% of the prescriptions. None of the prescriptions had Type A errorin our study.Conclusion:Â It was found that prescription errors are still prevalent. The prescribers' have to be updated about the prescribing guidelines and regularauditing should be done to avoid these errors.Keywords: Prescription errors, Obstetrics and gynaecology, Classification of errors

Natarajan, Anusha

Topno, Isabella

V, Rohith

English

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Vol 9, Issue 2, 2016Online - 2455-3891 Print - 0974-2441PRESCRIPTION ERRORS IN THE DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY: A CROSS-SECTIONAL, OBSERVATIONAL STUDYANUSHA NATARAJAN1*, ROHITH V2, ISABELLA TOPNO21Department of Pharmacology, JIPMER, Puducherry, India. 2Department of Pharmacology, Pondicherry Institute of Medical Sciences, Puducherry, India. Email: anushanatarajan29@gmail.comReceived: 30 December 2015 Revised and Accepted: 26 January 2016ABSTRACTObjective: Prescription writing is an art. Writing a correct prescription in compliance with the WHO guidelines requires regular practice. Mistakes in prescription writing are inevitable. Hence, this study was done to analyze the prescriptions from the Outpatient Department of Obstetrics and Gynaecology for errors. To analyze the prevalence and types of common prescribing errors in the Outpatient Department of Obstetrics and Gynaecology.Methods: This cross-sectional study was conducted in the Department of Pharmacy, Pondicherry Institute of Medical Sciences, Puducherry. 500 prescriptions from the Obstetrics and Gynaecology Outpatient Department were collected and analyzed. The study duration was 6 months (July-December 2014). The prescriptions were analyzed for errors.Results: Our study revealed that 30.8% of the prescriptions had, at least, one error in them. The majority of the prescriptions had the doctors’ sign and patient details written in them. The dose of the drug was missing in about 38% of the prescriptions. None of the prescriptions had Type A error in our study.Conclusion: It was found that prescription errors are still prevalent. The prescribers’ have to be updated about the prescribing guidelines and regular auditing should be done to avoid these errors.Keywords: Prescription errors, Obstetrics and gynaecology, Classification of errors.INTRODUCTIONThe prescription is a “written order from a registered medical practitioner, or new properly certified practitioners, such as dentist and veterinarian, together with a pharmacist to composite and distribute a specific medication for the tolerant.” The transaction is escorted by guidelines for the pharmacist to a specific type and quantity of preparation for that patient. The prescription consists of the directions for individual regarding the mode of administration of drugs, as well as dispensed for him [1].Medication errors are getting increasingly more established. These medication errors can be either (a) prescription errors or (b) dispensing mistakes. The issue of medication prescribing errors was little discussed until 1962 when Barker and McConnell in America (USA) first demonstrated that medication errors occur more frequent. They estimated a rate of 16 errors per 100 doses [2] and suggested how the apparent increasing rate of prescribing errors was proportionate to growing number of medications available. Subsequently, reporting systems for reporting medication errors were set up in the USA and Europe [3,4]. In 1995, a multidisciplinary group of 17 national organizations formed the National Coordinating Council for Medication Error Reporting and Prevention. Since, then there have been many other landmark developments with regard to reporting of prescribing errors [3]. Prescribing errors have led to the development of adverse drug events (ADEs), although fortunately most have a little risk or harm [5]. It is estimated that 3-24% involving prescriptions contain errors [6,7]. Prescribing errors develop a wide association with potentially serious health drawbacks. A large proportion of ADEs is related to prescribing errors, causing around 850,000 episodes of illness in the UK National Health Service [8-13].Prescription errors have been defined as “any preventable event that might cause or end result in inappropriate medication or patient harm once the medication is inside the associated with the healthcare professional, patient or consumer” [14]. Neville et al. have classified prescription errors into four categories based on the potential clinical outcomes [15]: Type A (potentially serious to patient); Type B (major nuisance-pharmacist/doctor contact required); Type C (minor nuisance-pharmacist must use professional judgment); and Type D (trivial). Gaining guidance for physicians prescribing pattern being able to identify prescribing is actually the fundamental step in improving the level of quality of prescription and patient care. This research was carried out to analyze the prescribing errors in the Outpatient Department of Obstetrics and Gynaecology in a tertiary care hospital in South India with an aim to establish the nature and forms of medication prescribing errors.Objectives1. To analyze the prevalence and types of common prescribing errors in the Outpatient Department of Obstetrics and Gynaecology2. To classify the prescription errors into four categories based on the potential clinical outcomes.METHODS•	 Cross-sectional	observational	study•	 Sample	size:	Randomly	selected	500	prescriptions	(outpatients)•	 Place:	Department	of	Pharmacy,	Pondicherry	 Institute	of	Medical	Sciences•	 Duration:	6	months	(July-December	2014)•	 The	prescriptions	were	analyzed	using	the	following	criteria	for	any	potential errors.Regarding prescription errorsThe following definition for “prescription error” was used through the study: “A clinically meaningful prescription error occurs when, as a result of a prescribing decision or prescription writing process, there is Research ArticleAsian J Pharm Clin Res, Vol 9, Issue 2, 2016, 233-235 Natarajan et al. 234an unintentional significant elimination of the probability of treatment being timely and effective or increase in the chance of harm when compared to generally accepted practice” [16]. Errors in prescription writing were further categorized as: [16-20].•	 Errors	of	omission	(when	rate	or	dose,	concentration,	dosage	form,	duration, frequency, route omitted and when prescriber signature missing)•	 Abbreviated	and	non-standard	drug	names•	 Error-prone	abbreviations,	symbols,	and	dose	designations•	 Prescribing	one	tablet	of	drug	when	to	be	found	in	more	than	a	single	strength of tablet•	 Writing	milligram	when	microgram	was	intended.The prescriptions were also classified in line with the classification of Neville et al. [15].Statistical methodsData are expressed as descriptive statistics.RESULTSA total of 500 outpatient prescriptions from the Department of Obstetrics and Gynaecology were analyzed for errors and were classified.Fig. 1 shows the percentage of prescriptions with errors. Of the 500 prescriptions scrutinized 30.8% had, at least, one error.Fig. 2 shows the details of prescriptions with a deficiency in patient details.Fig. 3 shows the percentage of prescriptions which were legible. Only 8% of the prescriptions were illegible.Fig. 4 shows the percentages of various errors of omission. The other errors of omission like using abbreviated and non-standard drug names, error-prone abbreviations, symbols and dose designations, prescribing one tablet of the drug when to be found in more than a single strength of tablet, writing milligram when microgram was intended were not found in any of the prescriptions that were analyzed.Fig. 5 shows the four categories of prescription errors based on classification put forth by Neville et al. [15].DISCUSSIONThe present study is the first of its kind to study and analyze the prescriptions from the Outpatient Unit of the Department of Obstetrics and Gynaecology for errors. In our study, we analyzed 500 prescriptions, out of which we found that 30.8% of the prescriptions were found to have at least one error. A total of 975 errors were identified in the 500 prescriptions. It has been estimated that 3-24% of all prescriptions contain errors [6,7]. A study done by Khoja et al. showed 18.7% of errors out of 5299 prescriptions which is much less when compared to the present study [21]. Another study done by Sapkota et al. showed 1233 errors in 305 prescriptions, which is higher than the present study [22].It was found that majority of the prescriptions had patients’ details written in them. Only a minority of them did not have the patients’ details: 4% did not have patients’ name, 5% did not have an age of the patient, 7% did not have the sex written, and 3% did not have the patients’ hospital number. The study was done by Nesar et al. showed a much higher rate when compared to our study [23]. Among these, Fig. 1: Prescriptions with errorsFig. 2: Patient detailsFig. 3: LegibilityFig. 4: Errors of omissionAsian J Pharm Clin Res, Vol 9, Issue 2, 2016, 233-235 Natarajan et al.235patient hospital number is the most important, as it would help for future reference.In our study, we found that majority of the prescriptions, 92% were legible contrary to the general belief that doctors’ handwriting is bad. This also makes the work of the pharmacist easy as he/she can read the prescription without any difficulty. The probable reason for good legibility of prescriptions in our study could be because most of the times the prescriptions are written by junior residents or interns and not directly by the consultant themselves. Rekha and Saurabh in her study showed that poor handwriting of the doctors’ was seen in 74.4% of the prescriptions, which is much higher than our study [24].The major errors of omission that we found in our study were 65% of prescriptions did not have the doctors’ profile, 52% of the prescriptions did not have the diagnosis mentioned, 62% of the prescriptions missed the route of administration, and in 66% of the prescriptions instruction regarding the use of the medication was missing. Sapkota et al. in her study showed that the errors of omission were much less compared to our study [22]. The results of Nesar et al. [23] and Poudel et al. [25] studies were similar to our study. In a study done by Ather et al. the rate of missing prescriber information was much high (90%) than our study [26].In our study, we also categorized the errors based on Neville et al. classification of prescription errors. We did not find any Type A errors in our study. Type B errors were maximum (10%), which included illegible handwriting, missing a dose, and missing frequency where the prescribing physician has to be contacted for clarification of the same. This was followed by Type C errors (9%) which included missing route and dosage form, where the pharmacist has to use his discretion to dispense the drugs. The results of our study are in concordance with the study done by Khoja et al. [21].Prescription errors are potentially preventable and concerted efforts by health providers, health consumers, and well-organized health delivery systems would lessen the incidence of such troubles [27].CONCLUSIONResearch results indicated that the prescription writing errors are significant which highlights requiring conducting of educational programs to develop the prescription writing skills of the prescribers. This could help in reducing prescription flaws. This study highlights the need for intervention to reduce prescription error in judgment. An electronic prescription writing system can be introduced to minimize these errors.REFERENCES1. Mehta RK. Prescription. Dispensing Pharmacy. 1st ed. Delhi: Vallabh Prakashan; 2000. p. 7.2. Barker KN, McConnell WE. How to detect medication errors. Mod Hosp 1962;99:95-106.3. Leape LL. Reporting of adverse events. N Engl J Med 2002;347(20):1633-8.4. About the National Reporting and Learning Service. National Patient Safety Agency. Available from: http://www.nrls.npsa.nhs.uk/about-us/. [Last accessed on 2015 Dec 12].5. Bates DW. Unexpected hypoglycemia in a critically ill patient. Ann Intern Med 2002;137(2):110-6.6. Sandars J, Esmail A. The frequency and nature of medical error in primary care: Understanding the diversity across studies. Fam Pract 2003;20(3):231-6.7. Cousins DH, Sabatier B, Begue D, Schmitt C, Hoppe-Tichy T. Medication errors in intravenous drug preparation and administration: A multicentre audit in the UK, Germany and France. Qual Saf Health Care 2005;14(3):190-5.8. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324(6):370-6.9. Leape LL. Error in medicine. J Am Med Assoc 1994;272:1851-7.10. Johnson JA, Bootman JL. Drug-related morbidity and mortality. A cost-of-illness model. Arch Intern Med 1995;155(18):1949-56.11. Rochon PA, Gurwitz JH. Drug therapy. Lancet 1995;346:32-6.12. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: Preliminary retrospective record review. BMJ 2001;322:517-9.13. Vincent C, Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P, et al. How to investigate and analyze clinical incidents: Clinical risk unit and association of litigation and risk management protocol. Br Med J 2000;320:777-81.14. United States Pharmacopoeia. The Standard. Rockville, Maryland, U.S. Pharmacopoeia; 1995.15. Neville RG, Robertson F, Livingstone S, Crombie IK. A classification of prescription errors. J R Coll Gen Pract 1989;39(320):110-2.16. Dean B, Barber N, Schachter M. What is a prescribing error? Qual Health Care 2000;9:232-7.17. Mortazavi SA, Hajebi G. An investigation on the nature and extent of occurrence of errors of commission in hospital prescriptions. Iran J Pharm Res 2003;2003:83-7.18. Institute of Safe Medication Practices, ISMP’s List of Error Prone Abbreviations, Symbols and Dose Designations, 2010. Available from: http://www.ismp.org/tools/errorproneabbreviations.pdf. [Last accessed on 2015 Dec 23].19. The National Coordinating Council for Medication Error Reporting and Prevention, Recommendations to Correct Error Prone Aspects of Prescription Writing. June; 2005.20. Available from: http://www.nccmerp.org/council/council1996-09-04.html. [Last accessed on 2015 Dec 23].21. Khoja T, Neyaz Y, Qureshi NA, Magzoub MA, Haycox A, Walley T. Medication errors in primary care in Riyadh City, Saudi Arabia. East Mediterr Health J 2011;17(2):156-9.22. Sapkota S, Pudasaini N, Singh C, Sagar G. Drug prescribing pattern and prescription error in elderly: A retrospective study of inpatient record. Asian J Pharm Clin Res 2011;4(3):129-32.23. Nesar S, Harris Shoaib M, Rahim N, Iffat W, Shakeel S, Bibi R. Prescription writing practices and errors in prescriptions containing cardiovascular drugs especially ACE inhibitors in Karachi, Pakistan. Asian J Pharm Clin Res 2015;8(4):53-5.24. Rekha B, Saurabh B. Evaluation of prevalence of medication errors in a multispecialty teaching hospital, Dehradun (Uttarakhand), India. Indian J Pharm Pract 2013;6(1):19-24.25. Poudel R, Piryani R, Shrestha S, Prajapati A, Adhikari B. Prescription errors and pharmacist intervention at outpatient pharmacy of Chitwan Medical College. J Chitwan Med Coll 2015;5(2):20-4.26. Ather A, Neelkantreddy P, Anand G, Manjunath G, Vishwanath J, Riyaz M. A study on determination of prescription writing errors in out-patient Department of Medicine in a Teaching Hospital. Indian J Pharm Pract 2013;6(2):21-4.27. Avery AJ, Sheikh A, Hurwitz B, Smeaton L, Chen YF, Howard R, et al. Safer medicines management in primary care. Br J Gen Pract 2002;52 Suppl: S17-22.Fig. 5: Classification of prescription errors

PRESCRIPTION ERRORS IN THE DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY: AÂ CROSS-SECTIONAL,Â OBSERVATIONALÂ STUDY

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PRESCRIPTION ERRORS IN THE DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY: AÂ CROSS-SECTIONAL,Â OBSERVATIONALÂ STUDY

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